Mid- and long-term quality of life assessments after laparoscopic fundoplication and refundoplication: a single unit review of more than 500 antireflux procedures

Role of Neuromodulators for the Management of Post-Gastric-Fundoplication Dyspepsia: A Retrospective Series

Post-fundoplication dyspepsia is a common complication of gastric fundoplication surgeries. This can be attributable to the loss of fundal relaxation, decreased gastric accommodation, and/or alterations in gastric motility and sensitivity following fundoplication. The role of neuromodulators in the management of such symptoms is unknown. We retrospectively assessed the efficacy of neuromodulators such as tricyclic antidepressants, buspirone, and mirtazapine for the management of post-fundoplication dyspepsia.

Health-related quality of life 10 years after laparoscopic nissen fundoplication-results of a community-based hospital

BACKGROUND

The lack of correlation between the symptomatic outcome after fundoplication and the results of objective measurements has been demonstrated. Therefore, subjective tools are needed to measure the outcomes of the treatment. Long-term results concerning health-related quality of life (HRQoL) after laparoscopic Nissen fundoplication (LNF) performed in a community-based hospital are lacking. The objective of this study was to describe HRQoL of an LNF cohort 10 years after surgery performed in a community-based hospital.

SUBJECTS AND METHODS

In 1997-1999, 107 LNFs were performed. The 15D questionnaire was mailed to all patients, and consent to participate in the study was requested. The patients who agreed to participate were interviewed. The resulting 15D profile and single index scores were compared with those of a sample of age-standardized general population (n=6053).

RESULTS

Of the 107 patients, 64 (59.8%) participated in the study (40 men; mean age, 61.9 years; range, 28-85 years). The mean 15D score for our patient group was 0.860 versus 0.888 for the age-standardized general population (P=.030). The mean 15D score of the patients who were satisfied with the surgical results was 0.870 (median, 0.890), which is clinically the same as that of the general population. Among the patients, dissatisfaction with the results of surgery decreased the mean 15D score by 0.069 (P=.023).

CONCLUSIONS

Our long-term follow-up study suggests that, in the majority of patients, HRQoL after LNF performed in a community-based hospital is similar to that of the general population, while the subjective failure of surgery leads to suboptimal results. The multidimensional 15D instrument seems a promising HRQoL instrument also when applied to gastroesophageal reflux disease patients.

Gastro oesophageal reflux disease (GORD)-related symptoms and its association with mood and anxiety disorders and psychological symptomology: a population-based study in women

BACKGROUND

Psychopathology seems to play a role in reflux pathogenesis and vice versa, yet few population-based studies have systematically investigated the association between gastro-oesophageal reflux disease (GORD) and psychopathology. We thus aimed to investigate the relationship between GORD-related symptoms and psychological symptomatology, as well as clinically diagnosed mood and anxiety disorders in a randomly selected, population-based sample of adult women.

METHODS

This study examined data collected from 1084 women aged 20-93 yr participating in the Geelong Osteoporosis Study. Mood and anxiety disorders were identified using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID-I/NP), and psychological symptomatology was assessed using the General Health Questionnaire (GHQ-12). GORD-related symptoms were self-reported and confirmed by medication use where possible and lifestyle factors were documented.

RESULTS

Current psychological symptomatology and mood disorder were associated with increased odds of concurrent GORD-related symptoms (adjusted OR 2.1, 95% CI 1.3-3.5, and OR 3.0, 95% CI 1.7-5.6, respectively). Current anxiety disorder also tended to be associated with increased odds of current GORD-related symptoms (p = 0.1). Lifetime mood disorder was associated with a 1.6-fold increased odds of lifetime GORD-related symptoms (adjusted OR 1.6, 95% CI 1.1-2.4) and lifetime anxiety disorder was associated with a 4-fold increased odds of lifetime GORD-related symptoms in obese but not non-obese participants (obese, age-adjusted OR 4.0, 95% CI 1.8-9.0).

CONCLUSIONS

These results indicate that psychological symptomatology, mood and anxiety disorders are positively associated with GORD-related symptoms. Acknowledging this common comorbidity may facilitate recognition and treatment, and opens new questions as to the pathways and mechanisms of the association.

Redo laparoscopic repair of benign esophageal disease

Laparoscopic fundoplication for gastroesophageal reflux disease has been associated with excellent symptom control. Compared with medical treatment, laparoscopic Nissen fundoplication has shown favorable control of typical reflux symptoms. However, in approximately 2% to 17% of patients, surgical treatment fails. The role of reoperative repair for reflux disease and the factors that contribute to it are examined.

A simple and effective technique for esophageal retraction and fundal translocation during laparoscopic fundoplication

Laparoscopic fundoplication is a widely used method for treating gastroesophageal reflux, but the standard methods of the procedure remain difficult and pose some risk of trauma to tissues. We therefore developed a technique in which the Goldfinger device is used for both the retraction of the esophagus and for the translocation of the fundus.

Long-term results of laparoscopic Nissen fundoplication due to gastroesophageal reflux disease. A ten year follow-up in a low volume center

BACKGROUND AND AIMS

Laparoscopic 360 degrees nissen fundoplication has been our routine surgical procedure since 1995, in the treatment of gastroesophageal reflux disease (GERD). We have reviewed our results of patients treated with laparoscopic Nissen fundoplication (LNF) during 1995-1998.

MATERIAL AND METHODS

170 patients have undergone LNF in our hospital since 1995. during the period of 1995-1998, 33 patients were treated. all patients were asked to return a structured follow-up questionnaire, using a Visick grading scale, after an average of 69 months (2003) and 117 months (2007). 29 questionnaires (90%) were answered in 2003, and 31 questionnaires (97%) were answered in 2007. one patient died at home before the first questionnaire in 2003, and is therefore not included. We present our results on LNF after an observation time of 117 months (range 99-144 months).

RESULTS

patient satisfaction after LNF is rated as very good or good (Visick 1-2) in 93% in 2003 and 97% in 2007. 97% of the patients would recommend the same treatment to other patients with similar symptoms at ten year follow up. One patient has undergone resurgery during follow up. Daily gas bloat and flatulence is reported in 52% in 2003 and 39% in 2007, and is the most common reason for reduced satisfaction. Five patients report of reflux symptoms, one patient daily and four patients sometimes, where the first patient still uses proton pump inhibitor (PPI) daily and three patients use PPI occasionally.

CONCLUSIONS

patient satisfaction after LNF treatment for gerd is high at long-term (10 years) follow-up. Bloating and flatulence persistently occurred to a great extent and the need for preoperative information regarding these symptoms is important.

Surgical reintervention after failed antireflux surgery: a systematic review of the literature

BACKGROUND

Outcome and morbidity of redo antireflux surgery are suggested to be less satisfactory than those of primary surgery. Studies reporting on redo surgery, however, are usually much smaller than those of primary surgery. The aim of this study was to summarize the currently available literature on redo antireflux surgery.

MATERIAL AND METHODS

A structured literature search was performed in the electronic databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials.

RESULTS

A total of 81 studies met the inclusion criteria. The study design was prospective in 29, retrospective in 15, and not reported in 37 studies. In these studies, 4,584 reoperations in 4,509 patients are reported. Recurrent reflux and dysphagia were the most frequent indications; intraoperative complications occurred in 21.4% and postoperative complications in 15.6%, with an overall mortality rate of 0.9%. The conversion rate in laparoscopic surgery was 8.7%. Mean(+/-SEM) duration of surgery was 177.4 +/- 10.3 min and mean hospital stay was 5.5 +/- 0.5 days. Symptomatic outcome was successful in 81.1% and was equal in the laparoscopic and conventional approach. Objective outcome was obtained in 24 studies (29.6%) and success was reported in 78.3%, with a slightly higher success rate in case of laparoscopy than with open surgery (85.8% vs. 78.0%).

CONCLUSION

This systematic review on redo antireflux surgery has confirmed that morbidity and mortality after redo surgery is higher than after primary surgery and symptomatic and objective outcome are less satisfactory. Data on objective results were scarce and consistency with regard to reporting outcome is necessary.

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center. Data on patients undergoing antireflux surgery in our unit has been prospectively collected and includes more than 600 primary laparoscopic antireflux operations since 1993. Laparoscopic reoperations have been performed between 1996 and 2005 for patients suffering recurrent reflux, dysphagia or severe gas bloat symptomatic despite medical treatment. All patients underwent preoperative barium studies and endoscopy with selective manometry and pH studies. Symptomatic outcomes were evaluated at 6 weeks and 12 months with Visick scores. Anatomical results were assessed with barium studies at between 6 and 12 months. Thirty-five laparoscopic reoperations were performed in 20 women and 13 men (median age 56 years). Primary surgery had been performed in our unit in 27 (77%) and elsewhere in eight (23%). Median time from primary surgery was 28.5 months (5-360). Two patients underwent a second reoperation. Indication was recurrent reflux in 28 (80%), dysphagia in five (14%) and gas bloat in two (6%). Thirty-two of the 35 reoperations (91.4%) were completed laparoscopically, median operating time was 120.5 min (65-210) and median hospital stay 2 days. There was no mortality and there were only five minor complications. Twelve-month follow-up was available for 32 reoperations (91%). Overall good symptomatic outcomes were obtained in 26 (74%) Visick I or II at 6 weeks and 24 of 32 (75%) at 12 months. In reoperations for dysphagia/gas bloat there was a relative risk of 4.26 of a poor symptomatic outcome (Visick III or IV) at 12 months compared to those for recurrent reflux (P < 0.05, Fisher's exact test). Laparoscopic reoperation is feasible with low conversion rates and minimal morbidity for patients who have undergone previous abdominal or thoracic hiatal repair. Symptomatic outcomes are generally good, particularly if the indication is recurrent reflux.

Gas-related symptoms after laparoscopic 360 degrees Nissen or 270 degrees Toupet fundoplication in gastrooesophageal reflux disease patients with aerophagia as comorbidity

BACKGROUND

Aerophagia is a rare but well-known comorbidity in patients with gastrooesophageal reflux disease. Particularly after laparoscopic Nissen fundoplication, it has proven to result in worse symptomatic outcome and a lower postoperative quality of life in comparison to patients without preoperative gas-related symptoms.

AIMS

Aim of the study was to compare the postoperative outcome in gastrooesophageal reflux disease patients with aerophagia as comorbidity after either laparoscopic 360 degrees 'floppy' Nissen fundoplication or 270 degrees Toupet fundoplication with main focus on the frequency and subjective impairment of gas-related symptoms.

PATIENTS AND METHODS

In 56 gastrooesophageal reflux disease patients, the comorbidity of aerophagia was diagnosed prior to laparoscopic antireflux surgery. Irrespective of their preoperative manometric findings, the patients were either scheduled to a laparoscopic 360 degrees 'floppy' Nissen (n=28) or a laparoscopic 270 degrees Toupet fundoplication (n=28). All patients have been analysed concerning the presence of gas-related symptoms preoperatively as well as 3 months after surgery. Additionally, the subjective degree of impairment was evaluated using a numerous rating scale (0=no perception/impairment, 100=most severe perception/impairment). The following symptoms have been analysed: ability/inability to belch, 'gas bloat', flatulence, postprandial fullness and epigastric pain.

RESULTS

Before surgery, there were no significant differences between both surgical groups. Three months after surgery, significant differences (p<0.05-0.01) were found: patients who underwent a laparoscopic 270 degrees Toupet fundoplication suffered from less impairing gas bloat, flatulence and postprandial fullness when compared with patients with a 360 degrees 'floppy' Nissen fundoplication. The majority of these patients were able to belch postoperatively but felt no impairment due to this symptom. In contrast, patients of the Nissen group felt a significant impairment due to the inability to belch.

CONCLUSION

Gas-related symptoms are very common in gastrooesophageal reflux disease patients with aerophagia as a comorbidity. Patients who undergo a laparoscopic Toupet fundoplication show less impairment in relation to gas-related problems compared with patients treated with a Nissen fundoplication for a follow-up period of at least 3 months. In the Toupet group, the ability to belch postoperatively seems to be a positive aspect from the patients' view which also improves the percentage of gas-related problems. However, long-term results are necessary.

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility.

METHODS

A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions.

RESULTS

In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 +/- 5.2 mmHg (range, 6.0-30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% +/- 8.3% (range, 70-100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett's progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1-46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results.

CONCLUSION

The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360 degrees fundoplication should not be contraindicated for patients with severe esophageal dysmotility.

Five-year subjective and objective results of laparoscopic and conventional Nissen fundoplication: a randomized trial

OBJECTIVE

The purpose of this prospective study was to compare the subjective and objective outcome of laparoscopic (LNF) and conventional Nissen fundoplication (CNF) up to 5 years after surgery as obtained in a multicenter randomized controlled trial.

SUMMARY OF BACKGROUND DATA

LNF is regarded as surgical treatment of first choice for refractory gastroesophageal reflux disease by many surgeons based on several short- and mid-term studies. The long-term efficacy of Nissen fundoplication, however, is still questioned as objective data gathered from prospective studies are lacking.

METHODS

From 1997 to 1999, 177 patients were randomized to undergo LNF or CNF. Five years after surgery, all patients were requested to fill in questionnaires and to undergo esophageal manometry and 24-hour pH-metry.

RESULTS

A total of 148 patients agreed to participate in the follow-up study: 79 patients after LNF and 69 after CNF. Of these, 97 patients (48 LNF, 49 CNF) consented to undergo esophageal manometry and 24-hour pH-metry. At 5 years follow-up, 20 patients had undergone reoperation: 12 after LNF (15%) and 8 after CNF (12%). There was no difference in subjective outcome, with overall satisfaction rates of 88% and 90%, respectively. Total esophageal acid exposure times (pH < 4) were 2.1% +/- 0.5% and 2.0% +/- 0.6%, respectively (P = 0.21). Antisecretory medication was taken daily in 14% and 16%, respectively (P = 0.29). There was no correlation between medication use and acid exposure and indices of symptom-reflux association (symptom index and symptom association probability). No significant differences between subjective and objective results at 3 to 6 months and results obtained at 5 years after surgery were found.

CONCLUSIONS

The effects of LNF and CNF on general state of health and objective reflux control are sustained up to 5 years after surgery and the long-term results of LNF and CNF are comparable. A substantial minority of patients in both groups had a second antireflux operation or took antisecretory drugs, although the use of those medications did not appear to be related to abnormal esophageal acid exposure.

Complications and antireflux medication use after antireflux surgery

BACKGROUND & AIMS

Although antireflux surgery is increasingly common, few studies have assessed the associated complications and health care use after surgery. The aim of this study was to estimate postoperative complications and continued use of antireflux medications and to identify predictors of complications.

METHODS

Through a review of the Department of Veterans Affairs administrative databases, all patients undergoing antireflux surgery from October 1, 1990, through January 29, 2001, were identified. Of 3367 patients identified, 222 were excluded as a result of a diagnosis of esophageal cancer, achalasia, or because there was no diagnosis related to gastroesophageal reflux disease. Medication use was determined for 2406 patients who had a minimum of 1 year of follow-up, including 1 or more outpatient visits at least 6 months after surgery and during the time when national pharmacy records were available.

RESULTS

Dysphagia was recorded in 19.4%, dilation was performed in 6.4%, and a repeat antireflux surgery was performed in 2.3%. The surgical mortality rate was .8%. Prescriptions were dispensed repeatedly for H2 receptor antagonists in 23.8%, proton pump inhibitors in 34.3%, and promotility agents in 9.2% of patients. Overall, 49.8% of patients received at least 3 prescriptions for one of these medications.

CONCLUSIONS

A moderate proportion of patients undergoing antireflux surgeries experienced complications and approximately 50% of patients received multiple prescriptions for antireflux medications at a median of 5 years of follow-up evaluation. Therefore, before surgery is performed, patients considering surgery should be counseled fully about the risk for complications and the likelihood of continued antireflux medication use.

Quality of Life Measurement in the Management of Gastroesophageal Reflux Disease

QOL measurement is being reported with increasing frequency in the surgical literature. The authors have found, as have others, that the use ofa generic instrument such as the SF36 in combination with a disease-specific instrument will provide the most comprehensive information. GERD isa significant health problem that primarily affects the QOL of a large segment of the population. New therapies for GERD continue to be developed and introduced into clinical practice. QOL assessment should bean important part of the evaluation of these new therapies.

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome

BACKGROUND

It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients.

METHODS

From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 +/- 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 +/- 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients' satisfaction with surgery. The data of a complete 5-year follow-up are available.

RESULTS

There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients' satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 +/- 11.6 points/EGD-negative vs 93.8 +/- 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 +/- 8.5 for EGD-negative vs 120.9 +/- 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 +/- 8.5).

CONCLUSION

We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.

The quality of life of gastroesophageal reflux disease patients waiting for an antireflux operation

BACKGROUND

The purpose of this trial was to measure the health-related quality of life (HRQL) of gastroesophageal reflux disease (GERD) patients waiting for an antireflux operation.

METHODS

A total of 120 patients waiting for a laparoscopic fundoplication were sent questionnaires measuring their symptoms and quality of life.

RESULTS

Ninety-five of the patients still needing an operation returned the questionaires and were included in the analysis. Thirty-one of 84 patients (37%) felt that the symptoms had worsened, and 51/90 (57%) were unsatisfied. Thirty percent suffered from throat or airway infections, 25% from swallowing difficulties, 48% from retrosternal pain, and 18% had asthma. The mean GERD HRQL score (0-45) was 21.7 (95% confidence interval, 19.7-23.7). Short Form-36 scores of this population were significantly worse when compared to patients with inguinal hernia or moderate asthma.

CONCLUSIONS

Patients waiting for a fundoplication seem to have a significantly decreased health-related quality of life due to poor symptom control regardless of continuous medical treatment.

Quality of life after esophageal surgery

QOL measurement is being reported with increasing frequency in the surgical literature. The authors and others have found that the use of a generic instrument such as the SF36 used in combination with a disease-specific instrument will provide the most comprehensive information. GERD is a significant health problem that primarily affects the QOL of a large segment of the population. New therapies for GERD continue to be developed and introduced into clinical practice. QOL assessment should be an important part of the evaluation of these new therapies. Similarly, the management of esophageal cancer and high-grade dysplasia is also controversial. QOL assessment should be a crucial factor in determining which surgical or nonoperative approach is used for these patients.

The impact of gastroesophageal reflux disease on quality of life

BACKGROUND

Quality of life as a medical endpoint has become an important measure in clinical research.

METHODS

In this article, we review the recent literature that has examined the impact of gastroesophageal reflux disease (GERD) and its treatment of quality of life.

RESULTS

The increasing interest in measuring patients' quality of life as an outcome reflects an increasing awareness that traditional physiological endpoints often do not correlate well with patients' functional status, general well-being, and satisfaction with therapy. It has been shown that GERD has a significant impact on patients' quality of life; therefore, improvement of quality of life is one of the major goals of GERD treatment. This can be achieved by medical as well as surgical treatment.

CONCLUSION

In addition to the patients' perspective, quality of life is one of the major endpoints in medical research that will help provide more selective treatment regimens for our patients.

The outcome of laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication

It is well known that several patient-related factors are able to affect the surgical outcome such as quality of life or symptom relief after laparoscopic antireflux surgery. The aim of the current study was to evaluate and compare surgical outcome up to 1 year after laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication. Based on a three-level grading of subjective compliance with primary antireflux medication, a total of 140 patients undergoing antireflux surgery were divided into three subgroups: group 1/TC (totally compliant; n = 60), group 2/PC (partially compliant; n = 49); and group 3/NC (noncompliant; n = 31). Gastrointestinal Quality of Life Index (GIQLI), satisfaction with surgery, and the subjective degree of dysphagia as well as traditional outcome data (e.g., DeMeester score, lower esophageal sphincter pressure, side effects) were evaluated in all patients. As a result of surgery, only patients out of group 1/TC (GIQLI, preoperative 86.3 + 9.3 vs. 1 year postoperatively 123.1 + 7.2 points) and group 2/PC (GIQLI, preoperative 94.2 + 8.6 vs. 1 year postoperatively 120.8 + 7.8 points) showed a significant quality of life improvement that remained stable for at least 1 year (P < 0.05-0.01). In contrast, group 3/NC (GIQLI, preoperative 100.2 + 6.1 vs. 1 year postoperatively 117.2 + 9.8 points) patients had no significant quality of life improvement and patient satisfaction with surgery was less good when compared with that of the other groups. In these patients, also the subjective degree of postoperative dysphagia was significantly (P < 0.05-0.001) higher during the 1-year follow-up when compared with patients from group 1/TC or group 2/PC. A total of 42% of group 3/NC patients reported surgical side effects, whereas only 3% from group 1/TC and 10% from group 2/PC stated to be affected by any new symptoms (P < 0.0001). None of group 1/TC or group 2/PC patients suffered from recurrent symptoms or underwent laparoscopic reoperation. Of group 3/NC, a total of four patients (13%) needed any kind of additional intervention in relation to antireflux surgery (reoperation, n = 3; pneumatic dilatation, n = 1). There were no significant differences between the three groups when postoperative values of esophageal manometry and 24-hour pH monitoring were compared. What the current study does show is that the efficacy and the surgical outcome after laparoscopic antireflux surgery partly depends on the subjective degree of patient compliance with primary antireflux medication. Patients with no compliance in relation to former antireflux medication should generally not be refused antireflux surgery. But these patients should be evaluated with great care before surgery and should also be informed that surgical outcome may be affected in several aspects.

Psychological and emotional aspects of gastroesophageal reflux disease

A synergy exists between the psychological and physiological aspects of esophageal and other gastrointestinal symptoms. Based on a biopsychosocial model of disease, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) has been under study. This article reviews psychological and emotional factors influencing GERD symptoms and treatment.

Expectations of patients with gastroesophageal reflux disease for the outcome of laparoscopic antireflux surgery

Goals of gastroesophageal reflux disease (GERD) treatment are symptom relief, healing of esophagitis, prevention of complications, and prevention of relapses. The aims of the current study were to evaluate a selected group of patients referred to our Department of General Surgery for presurgical examination (N = 70: 41 males and 29 females) for their expectations about laparoscopic antireflux surgery and to compare these expectations with the official medical treatment goals. The leading expectations for laparoscopic antireflux surgery were as follows: (1) for 92.8%, abatement of GERD-related symptoms, especially heartburn, regurgitation, and pain; (2) for 84.3%, a return to normal daily activities and life such as eating and drinking habits, sleeping habits, or work-related aspects; (3) for 72.9%, an improvement in quality of life; (4) for 52.9%, a successful surgical intervention without any complications or side effects; and (5) for 48.6%, protection from a Barrett esophagus and cancer risk. In contrast, only two patients answered that they would expect normalization of pH values and healing of esophagitis. The data show that the majority of patients have clear expectations about laparoscopic antireflux surgery. These expectations are partly related to official medical treatment goals. In general, patient-related aspects of outcome concerning expectations should be included as a standard in all official goals of GERD treatment and also in medical outcome studies. One of these aspects should absolutely be patients' quality of life.

Long-term follow-up after laparoscopic refundoplication for failed antireflux surgery: quality of life, symptomatic outcome, and patient satisfaction

Quality of life and patient satisfaction have been shown to be important factors in evaluating outcome of laparoscopic antireflux surgery (LARS). The aim of this study was to evaluate data pertaining to quality of life, patient satisfaction, and changes in symptoms in patients who underwent laparoscopic redo surgery after primary failed open or laparoscopic antireflux surgery 3 to 5 years postoperatively. Between March 1995 and June 1998, a total of 27 patients whose mean age was 57 years (range 35 to 78 years) underwent laparoscopic refundoplication for primary failed open or laparoscopic antireflux surgery. Quality of life was evaluated by means of the Gastrointestinal Quality of Life Index (GIQLI). Additionally, patient satisfaction and symptomatic outcome were evaluated using a standardized questionnaire. Three to 5 years after laparoscopic refundoplication, patients rated their quality of life (GIQLI) in an overall score of 113.4 points. Twenty-five patients (92.6%) rated their satisfaction with the redo procedure as very good and would undergo surgery again, if necessary. These patients were no longer taking any antireflux medication at follow-up. Two patients (7.4%) reported rare episodes of heartburn, which were managed successfully with proton pump inhibitors on demand, and four patients (14.8%) reported some episodes of regurgitation but with no decrease in quality of life. Seven patients (25.9%) suffer from mild-to-moderate dysphagia 5 years postoperatively, and 12 patients (44.4%) report having occasional chest pain but no other symptoms of gastroesophageal reflux disease. Nine of these patients suffer from concomitant cardiopulmonary disease. Laparoscopic refundoplication after primary failed antireflux surgery results in a high degree of patient satisfaction and significant improvement in quality of life with a good symptomatic outcome for a follow-up period of 3 to 5 years after surgery.